Reassessing Preemptive Kidney Transplantation in the United States

Are We Making Progress?

Abstract

Background 

Preemptive kidney transplantation (preKT) is associated with higher patient survival, improved quality of life, and lower costs. However, only a minority of patients receives preKT. The aim of this study was to examine changes over the past decade in rates of preKT, focusing on living donor kidney transplantation (LDKT) and specifically recipients who underwent kidney transplantation within 1 year of initiating dialysis.

Methods 

Using United Network of Organ Sharing data, we examined retrospectively all kidney transplant candidates (n = 369 103) and recipients (n = 141 254) from 2003 to 2012 in the United States focusing on LDKT (n = 47 108). Predictors of preKT were examined, and patient and graft survival were compared for preKT, pretransplant dialysis less than 1 year, and pretransplant dialysis recipients of 1 year or longer.

Results 

PreKT occurred in only 17% of recipients overall and 31% of LDKT recipients. Medicare patients (odds ratio [OR], 0.29; 95% confidence interval [95% CI], 0.28-0.31), diabetics (OR, 0.75; 95% CI, 0.69-0.80), and minorities (Hispanics OR, 0.62; 95% CI, 0.57-0.68 and African Americans OR, 0.58; 95% CI, 0.53-0.63) were less likely to receive preKT. Dialysis recipients for less than 1 year comprised 30% of nonpreemptive LDKT. Dialysis recipients of less than 1 year had similar patient survival to preKT (5 years: preKT, 94%; dialysis < 1 year, 94%; dialysis ≥ 1 year, 89%; P < 0.01), but decreased death-censored graft survival (5 years: preKT, 93%; dialysis < 1 year, 89%; and dialysis ≥ 1 year, 89%; P < 0.01).

Conclusions 

PreKT remains an unrealized goal for the majority of recipients. Medicare patients, diabetics, and minorities are less likely to receive preKT. Almost one third of nonpreemptive LDKT recipients were dialyzed for less than 1 year, highlighting an important target for improvement.

In Brief

Recent analysis of the United Network of Organ Sharing Data shows that preemptive kidney transplantation occurred in 17% of recipients overall and 31% of living donor recipients. There is a trend for an increased incidence of thrombosis that has been seen in prior analyses.

Compared with dialysis, kidney transplantation leads to higher patient survival, improved quality of life, and lower costs.^1-4 In reality, the majority of patients with end-stage renal disease (ESRD) undergo both therapies, receiving several years of dialysis prior to kidney transplantation. However, limiting dialysis time is an important goal as increased time on dialysis before transplant is associated with decreased patient and graft survival.^5-8

Given the shortage of deceased donor organs, a period of pretransplant dialysis is likely obligatory for most deceased donor kidney candidates. However, it is concerning that the majority of recipients of living donor kidneys also undergo dialysis pretransplantation. Even with living donor kidney transplantation (LDKT), historically, fewer than one quarter of recipients undergo preemptive kidney transplantation (preKT).^7,9,10

In the past several years, interest in preKT has increased.^4,11,12 The report from the National Kidney Foundation conference in 2007 suggested several tactics for increasing preKT.¹¹ However, it is unclear if increased awareness has led to changes in practice.

The aim of the current study was to examine recent (2003 to 2012) rates of preKT in the United States, with a particular emphasis on recipients of living donor kidneys. In addition to studying changes in the rates of preKT, we were interested in any changes in demographics for preKT versus nonpreemptive KT in this time frame. Finally, we focused on recipients of living donor kidney transplants who underwent only a short course of dialysis (<1 year) to begin to understand the demographics of non-preemptive recipients who might be more likely to avoid dialysis.

MATERIALS AND METHODS

Using national data from the United Network of Organ Sharing (UNOS), we examined retrospectively all adult and pediatric kidney transplant recipients who were transplanted from June 2003 to September 2012. This cohort included 47 018 patients who received a LDKT and 95 814 patients who received a deceased donor kidney transplant (DDKT). Recipients of multiorgan transplants (including kidney-pancreas transplants) were excluded. The majority of our analyses focused on LDKT recipients as we believe LDKT provides the greatest potential for increasing the rate of preKT. A flowchart describing inclusion and exclusion criteria used in this analysis is provided in Appendix A (SDC, https://links.lww.com/TP/B200).

We analyzed the rates of preKT over the study period. We examined duration of dialysis before transplantation in nonpreemptive transplant recipients and divided these patients into less than 1 year of dialysis and 1 year or longer of dialysis subgroups. We compared donor and recipient characteristics for preKT, dialysis less than 1 year, and 1 year or longer of dialysis pretransplantation subgroups, including age at transplant, sex, race, renal diagnosis, primary payer at time of transplant, ABO blood type, and recipient sensitization according to calculated panel reactive antibody (cPRA) at the time of transplant. We compared patient survival and overall and death-censored graft survival for living donor preKT, dialysis less than 1 year, and 1 year or longer of dialysis pretransplantation.

Statistical Analyses and Missing Data

Categorical variables were compared using χ² statistics, and t test statistics were used to compare continuous variables. Missing data for recipient demographics are reported in the tables and was combined with “other” for variables with a large number of small frequency responses, such as renal diagnoses and race. Time on dialysis before transplantation was not available for 19% of nonpreemptive transplant recipients. Mandatory reporting of cPRA was not instituted until 2007 and was thus only available for 53% of patients, specifically those listed from 2007 to 2012.

Patient and (overall and death-censored) graft survival were compared with Kaplan-Meier analysis and log-rank tests. Additionally, Cox proportional hazards models were used to compare survival after adjusting for recipient factors (age at transplant, sex, race, ABO, etiology of renal disease [diabetes, hypertension, glomerulonephritis, and polycystic kidney disease {PCKD}], primary payer [medicare vs private insurance], body mass index [BMI], and cPRA), living donor factors (age, sex, race, and BMI), and transplant factors (cold ischemic time and HLA mismatch). Factors included in survival models were chosen a priori based on clinical significance. Recipient characteristics that were statistically different between cohorts according to preemptive status were included in adjustment to address potential confounding. Multivariate logistic regression was used to identify recipient predictors of receiving preKT. Hazard ratios (HR) and odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Schoenfeld residuals tests were used to confirm the proportional hazards assumption. Goodness of fit was assessed according to χ² statistics for survival models including global test statistics for nested models and according to the Cox-Snell pseudo-R² statistics for multivariate logistic regression. A 2-sided P value less than 0.01 was considered significant given the large sample size of this analysis. All analyses were performed with STATA software (version 11.2, College Station, TX). This study was approved as exempt by the Mayo Clinic Institutional Review Board as it involves deidentified publicly available data.

RESULTS

Overall Kidney Transplant Rates

From June 2003 to September 2012, 141 254 kidney transplants were performed in the United States. The majority were from deceased donors (94 881 deceased donors versus 46 373 living donors). The majority of patients underwent both dialysis and transplantation, with only 17% (24 609/141 254) transplanted preemptively over the study period. The rate of preKT was higher for living donor recipients than deceased donor recipients (31%, 14 503/46 373 versus 11%, 10 106/94 881, P < 0.0001). However, given the large number of DDKTs, 41% (10 106/24 609) of all preemptive transplants were from deceased donors.

Dialysis Time Before Transplantation

Dialysis time before transplantation varied according to donor type (Table 1). Seventy-nine percent of DDKT recipients were dialyzed for more than 2 years, whereas only 6% were dialyzed for less than 1 year. In contrast, only 38% of LDKT recipients were dialyzed for more than 2 years, whereas 32% were dialyzed for 1 to 2 years and 30% were dialyzed for less than 1 year.

TABLE 1: Proportion of preemptive kidney transplant according to donor type and dialysis time before transplant in nonpreemptive transplants

Changes in Preemptive Transplant Rates Over Time

In the past decade, the proportions of preKT have increased marginally from 12% in 2003 to 18% in 2012. This was primarily related to an increase in living donor preKT from 23% in 2003 to 34% in 2012 (Figure 1). During this time, the overall number of LDKT increased by 25%. The number of patients dialyzing less than 1 year before LDKT was stable at approximately 750 per year.

FIGURE 1: Annual trends in preemptive, dialysis for less than 1 year, and dialysis for 1 year or longer before living donor kidney transplantation. *Data for 2003 and 2012 are not displayed because only partial year data were available for analysis.

Preemptive LDKT: Recipient Characteristics

The LDKT recipient characteristics for preKT, dialysis for less than 1 year, and dialysis for 1 year or longer before transplantation are presented in Table 2, and a univariate analysis of predictors of living donor preKT is presented in Table 3. Private insurance and white race were 2 factors associated with preKT. In LDKT recipients with private insurance, 40% (11 003/27 083) were preKT. Compared to patients with private insurance, 16% (2673/16 592) of LDKT recipients with Medicare had a preKT corresponding to an adjusted OR of 0.29 (95% CI or 0.28-0.31) of receiving a preKT. African Americans had an OR of 0.58 (95% CI, 0.53-0.63) and Hispanic/Latinos an OR of 0.62 (95% CI, 0.57-0.68) compared with whites. Additionally, increased education level was associated with increased rates of preKT (OR, 1.16 per increased level; 95% CI, 0.13-0.18).

TABLE 2: Recipient characteristics of preemptive compared with nonpreemptive living donor kidney transplant recipients

TABLE 3: Predictors of preemptive transplantation in adult LDKT recipients

The rate of preKT also varied with the cause of renal failure: 65% (2707/4181) of recipients with PCKD, 37% (4111/11 276) of recipients with glomerulonephritis, and 28% (2289/8143) of patients with diabetes underwent preKT. The preKT also varied by age group, with 34% (746/2179) of recipients younger than 20 years receiving preKT compared with 23% (1156/5096) of 20 to 29 years, 27% (2075/7561) of 30 to 39 year old, 33% (10 515/31 500) of 40 to 79 years old, and 29% (10/34) of LDKT recipients older than 79 years. For older patients, odds of preKT with living donors were increased which was highest in the recipients older than 70 years (OR, 2.54; 95% CI, 2.21-3.91) likely reflecting an understanding by transplant clinicians of the dangers of waiting for a kidney and prolonged dialysis in older candidates and thus a higher selection rate of patients who present early with a donor.

Over time, there were improvements in preKT rates among minorities, with the largest increase being in Hispanic/Latino patients. Twenty-four percent (405/1705) of African American LDKT recipients in 2010 to 2012 underwent preKT compared with 20% (333/1708) in 2003 to 2005 (P < 0.01). For Hispanic/Latino LDKT recipients, preKT increased from 19% (299/1607) in 2003 to 2005 to 26% (488/1900) in 2010 to 2012 (P < 0.01). Additionally, there was some improvement in the rate of preKT in adult Medicare LDKT recipients during the period studied, with 20% (917/4,590) of Medicare patients receiving preKT in 2010 to 2012 compared with 15% (601/3985) in 2003 to 2005 (P < 0.01) (Table 4).

TABLE 4: LDKT demographics for preKT, dialysis < 1 y, and dialysis ≥ 1 y for the early and late periods

The degree of sensitization had an impact on the rate of preKT. In patients with cPRA greater than 80%, 22% (202/914) underwent preKT, compared with 35% (858/2422) of recipients with a cPRA of 20% to 80% and 40% (7185/17 769) of recipients with cPRA less than 20% (Table 2).

Pretransplant Dialysis Recipients for Less Than 1 Year

We hypothesized those patients who dialyze for only a short time before transplantation might undergo preKT if approached differently. Overall, dialysis recipients for less than 1 year generally were similar to preKT recipients with respect to age, blood group, cPRA, and incidence of diabetes, hypertension, and glomerulonephritis (Table 2). The percentage of dialysis recipients for less than 1 year that were white was lower (67%) than preKT (77%), but higher than those dialyzing for 1 year or longer (52%). Although rates of preKT appeared to be similar between African Americans and Hispanic/Latinos, there was a slightly higher rate of dialysis less than 1 year in Hispanic/Latinos recipients. Among all recipients who underwent nonpreemptive LDKT, 25% (1152/4670) were dialysis recipients for less than 1 year in Hispanic/Latinos compared with 20% (903/4558) in African Americans.

Insurance status appeared to be an important factor not only in avoiding dialysis but also in the duration of dialysis before LDKT. Medicare was the primary payer in 18% of preKT, 31% of dialysis recipients for less than 1 year, and 56% of patients dialyzing for longer than 1 year compared with private insurance in 76% of preKT, 64% of dialysis recipients for less than 1 year, and 38% of dialysis recipients for 1 year or longer (Table 2).

Regional Variation

There was a significant variation in the proportion of preKT according to UNOS region (Figure 2), ranging from 30% in region 5 to 44% in regions 7 and 9 (P < 0.001) during the study period. Regions with a high proportion of LDKT (region 7: 44% LDKT/KT and region 9: 37% LDKT/KT) were the regions identified as having highest proportion of preKT for both LDKT (Figure 2) and all KT (data not shown). However, differences in rates of preKT are likely multifactorial, as region 1 had one of the lowest rates of preKT (32% preKT for LDKT and 14% preKT for KT overall) despite having one the highest proportions of LDKT (38% LDKT/KT; range for all regions, 24-44%) and one of the lowest median waitlist times (715 days for region 1 compared with median of 1499 days and interquartile range of 1103-1902 days for all regions). Some regions with lower rates of preKT had a higher incidence of dialysis for less than 1 year, such as region 1 with 32% preKT and 28% dialysis for less than 1 year (Figure 2).

FIGURE 2: Regional variation in rate of preemptive and dialysis for less than 1 year living donor kidney transplant recipients.

We found no association between higher proportions of Medicare patients or minorities and regions with high or low proportions of preKT. Interestingly, the 3 regions with highest proportion of preKT (regions 2, 7, and 9) had the lowest proportion of diabetics (20%, 13%, and 11%, respectively), and the 4 regions with lowest proportion of preKT (1, 4, 5, and 11) had highest proportions of diabetics (31%, 43%, 50%, and 55%).

LDKT Patient and Graft Survival

Dialysis recipients for less than 1 year had similar patient survival to preKT with 5-year survival of 94% for preKT and dialysis for less than 1 year compared with 89% for recipients who were dialyzed 1 year or longer (log rank: P < 0.01) (Figure 3A). Overall graft survival was significantly different for each group (log rank: P < 0.01) (Figure 3B) with 5-year survival of 87% for preKT, 83% for dialysis of less than 1 year, and 79% for dialysis for 1 year or longer. However, when death-censored graft survival was examined separately, dialysis recipients for less than 1 year had significantly inferior graft survival to preKT and similar to recipients who were dialyzed for 1 year or longer (5-year death-censored graft survival: 93% for preKT and 89% for dialysis <1 year and ≥1 year recipients, log rank: P < 0.01) (Figure 3C).

FIGURE 3: Unadjusted patient, overall graft, and death-censored graft survival after living donor kidney transplant according to preemptive status.

Additionally, we compared survival for preKT, dialysis for less than 1 year, and dialysis for 1 year or more, adjusting for recipient factors (age at transplant, sex, race, ABO, etiology of renal disease [diabetes, hypertension, glomerulonephritis, and PCKD], insurance [medicare vs private insurance], BMI, and cPRA), living donor factors (age, sex, race, and BMI), and transplant factors (cold ischemic time and HLA mismatch). For patient survival, preKT had an HR of 0.55 (95% CI, 0.48-0.64) and dialysis for less than 1 year had an HR of 0.65 (95% CI, 0.55-0.76) when compared to the reference group of recipients who were dialyzed for 1 year or longer. For death-censored graft survival, significant improvements in survival were seen for preKT and dialysis for less than 1 year when compared to recipients who were dialyzed for 1 year or longer (preKT: HR, 0.61; 95% CI, 0.53-0.71 and dialysis <1 year: HR, 0.79; 95% CI, 0.68-0.90).

Survival for preemptive LDKT kidney transplant recipients was compared according to the year of transplant to determine if there were improvements over time. Death-censored graft survival improved significantly for recipients from the later period (2009-2012) when compared with the early period (2003-2005) (log rank: P = 0.0001) with 3-year death-censored graft survival of 94% for 2003 to 2005, 96% for 2006 to 2008, and 96% for 2009 to 2012 (Figure 4C). However, patient survival was not significantly different according to transplant year (log rank: P = 0.35), and as such there were no significant improvements in overall graft survival according to transplant year (log rank: P = 0.08) (Figures 4A and B).

FIGURE 4: Patient and graft survival for preemptive LDKT transplant recipients according to year of transplant.

DISCUSSION

PreKT remains an unrealized goal for the majority of patients. More than a decade ago, the rate of preKT in the United States was 13% overall and 22% to 25% for LDKT.^7,9 In this study, we identified that the rate of preKT for the subsequent decade (2003-2012) was 17% overall and 31% for LDKT representing negligible change over the past decade. This small change is cause for concern given the large body of evidence demonstrating improved outcomes with preKT^5,6,9,13 and national initiatives aimed at augmenting preKT.¹¹ Recent analysis of preemptive DDKT shows that rates remain persistently low at 9%.¹⁴ In this study, we focused primarily on patients who eventually underwent LDKT because we believe that this group might be able to undergo preKT if managed differently. The rate of living donor preKT increased from 23% in 2003 to 34% in 2012. However, the majority of patients who eventually received an LDKT still underwent a period of dialysis before transplantation—many for more than a year. Moreover, this slightly more than 10% increase in the proportion of preKT for LDKT was during a period of more than 25% growth in the rate of LDKT.

Additionally, we sought to characterize with increased granularity a group of patients who underwent only a brief course of dialysis (<1 year). We showed that these patients represented one third of the nonpreemptive LDKT, highlighting a novel but potentially meaningful target for initiatives directed at augmenting preKT.

Most concerning is the finding that nonmedical conditions, such as the lack of private insurance and race/ethnicity, seemed to play major roles in the inability to receive a preKT. Interestingly, these same barriers were identified in studies examining DDKT recipients.^14-16 Medicare as the primary payer for kidney transplantation in the United States is a critical factor in promoting preKT. Medicare entitlement begins with initiation of dialysis or 2 months before kidney transplant once the transplant is performed. As such, there can be clear financial disincentives facing transplant centers due to the complexity of covering pretransplant costs associated with the evaluation of potential living donors and uncertainties regarding coverage for those who ultimately are eligible for Medicaid or Medicare part A only.¹¹ We acknowledge that disparities in access to health care including access to transplant and especially early preKT are impacted by the patient's socioeconomic status based on an abundance of literature on this topic. Accordingly, we did find that patient education level was predictive of preKT. However, we believe that differences in preKT are likely multifactorial. Given that current Medicare policies are not currently structured to incentive preKT, we suggest that this may be a contributing factor to the low rate of preKT in Medicare recipients. The disparity in rates of preKT between Medicare and private insurance patients clearly points out the opportunity cost of current Medicare practices and policies, and given the frequency of Medicare as the primary payer for kidney transplant, there is a tremendous opportunity to influence practice through carefully constructed policies aimed at augmenting earlier referral and transplant.

Also, we demonstrated that Hispanics have a higher proportion of dialysis less than 1 year among nonpreemptive LDKT recipients. Additionally, diabetics had a very low rate of preKT despite the fact that most of these recipients are known to have diabetes for many years and experience a slow progression of associated nephropathy. In contrast, recipients with PCKD who also typically experience a slow progression of renal failure had a high rate of preKT. Given the frequency of diabetes in the U.S. population and evidence demonstrating a survival benefit for this group of patients with preKT,^15,17 efforts should be made to improve earlier referral of diabetics with progressive renal decline.

Additionally, the existence of regional variation could provide interesting avenues of insight into some barriers to augmenting preKT. We showed that these differences were more complicated than simple differences in the utilization of LDKT or median wait times as seen with the low rate of preKT in region 1. When examining factors related to regional variation, we again saw a disparity faced by diabetics in receiving preKT despite a typically indolent disease course. Further study of this specific group of patients may yield improved insight into the barriers to preKT.

We believe improvements in preKT might be possible in Hispanics, diabetics, and Medicare recipients with improved education and emphasis on early referral to a transplant center. In 2002, the Kidney Disease Outcomes Quality Initiative guidelines set treatment metrics for the management of chronic kidney disease patients.¹¹ The guidelines focus primarily on preparing patients with ESRD for dialysis rather than for transplantation. Although “fistula first” is a laudable goal, we suggest that there should be a similar emphasis on avoidance of dialysis when possible. Not only would this lead to improved quality of life and life expectancy but also would result in cost savings. Medicare expenditures are estimated to be greater than US $87 000 per year for hemodialysis compared with US $33 000 per year after kidney transplant.¹⁸ Similarly, 2 years after either initiation of dialysis or transplantation, preKT was associated with a 34% decrease in expenditures compared with patients who underwent 12 months of dialysis before transplantation.¹¹ The bulk of costs associated with dialysis are incurred in a 3-month time interval around the initiation of dialysis.¹¹ Additionally, mortality incidence peaks in the second month after initiation of dialysis.¹⁸ This further highlights the potential tremendous impact of targeting increases in preKT for those patients who underwent a short duration of dialysis before transplantation. Medicare patients are clearly 1 group of recipients who currently are disadvantaged from receiving preKT and would benefit from policy reform to address these inequities.

One limitation of this analysis is the possibility of lead time bias in terms of the survival benefit seen with preemptive transplantation. Grams et al¹⁹ identified in their analysis higher estimated glomerular filtration rates over time in the recipients of preemptive transplantation. Prior studies have shown no improvement in graft survival with very early preKT (preKT at increased eGFR).^20,21 We are not advocating for transplanting patients as early as possible while native renal function remains preserved, but rather assembling resources and structuring processes to allow for a “just in time” approach. We do believe that the greatly improved patient survival seen in the recipients who were dialyzed for less than 1 year (which more closely mirrored patient survival with preKT and was higher than the survival of those who dialyzed longer) does suggest a true patient benefit of earlier transplant and limiting time on dialysis. This patient survival benefit is likely the source of the allograft survival advantage seen with preKT as supported by prior evidence.²²

Additionally, given the limits of posttransplant complication data reported to UNOS, our analysis has only focused on potential survival benefits and cannot provide meaningful answers to other important concerns that have been raised in relation to preKT. Ojo et al²³ had previously shown that patients with pretransplant peritoneal dialysis and those who underwent preKT had higher rates of graft thrombosis. In our analysis, there were no statistically significant differences in graft thrombosis between groups according to preemptive status (preKT = 11/333, 3% vs non-preKT 19/1266, 1.5%; P = 0.11) or according to dialysis type (peritoneal vs hemodialysis). This lack of significance could be due to insufficient power given the very small event rate; however, it is beyond the scope of this analysis to determine causality for this most unfortunate outcome. We would suggest that concerns about increased risks of graft thrombosis after preKT could be due to delays in detection of technical problems in patients who still produce urine masking early allograft function. As such, at our center, immediate postoperative ultrasound is routinely utilized to assess adequacy of perfusion and vascular anatomy in immediate postoperative period. It is beyond the scope of this analysis to determine the etiology of graft thrombosis in these patients, whether preKT patients are truly at increased risks, or what preventive measures are needed to address these concerns. Institutional data will be needed to address these important questions.

A second limitation inherent to this type of analysis is that it is based on national registry data that lack granularity and may not include detailed data regarding other possible barriers to preKT. Some patients may encounter medically necessary delays before transplantation, such as a period of observation to rule out cancer recurrence or to undergo psychiatric or substance abuse treatment, and such circumstances cannot be gleaned from registry data. A more detailed study is needed to determine the actual barriers to preKT. Prior efforts at understanding barriers to preKT have shown that almost half (45%) of patients began their evaluation for transplant before initiating dialysis and that 75% of these patients indicated a desire to undergo preKT rather than starting dialysis.¹⁰ In addition, more than 60% of patients were followed up by a nephrologist for more than 6 months before the initiation of dialysis.^10,11 Given this, targeting earlier initiation and completion of a transplant evaluation could provide a meaningful increase in preKT. This certainly is not the first evidence to suggest the importance of earlier referral and encourage its more widespread practice; however, as we have demonstrated, large changes have not occurred in terms of improving earlier referral. This might suggest the need for increased incentives such as pay for performance measures to augment referral. Currently, Medicare initiatives are aimed at mandating referral once patients are under the care of a dialysis center, but this is obviously too late to target improving preemptive transplantation.

Although this highlights the focus of physician education and prioritization in improving the rate of preKT, continuing to improve patient education about living donation remains an important objective as well. Weng et al¹⁰ found that more than 50% of the patients were initially expected to receive a DDKT. Given that the waiting times exceed 5 years in much of the United States and longer in some regions, the ability to receive a timely DDKT is a naive goal.

We conclude that although there have been slight improvements in the rates of preKT over the past several years, rates overall remain quite low. The identification of diabetes, Medicare as primary payer, and race/ethnicity as recipient characteristics associated with lower rates of preKT in our study evaluating LDKT and those by others evaluating DDKT highlights how truly disadvantaged these patients are.¹⁴

Further studies focused on the challenges facing Hispanics, diabetics, and Medicare recipients and evaluation of factors behind regional variation are needed to elucidate barriers to preKT. We suggest that changes in Medicare policies combined with early and better education of patients, potential donors, and referring physicians are necessary to ensure wider application of the preKT—the ideal treatment for ESRD.